An Unbelievable Experience
Mike had a disappointing thought this morning … he thought it was Thursday. Instead, it’s Wednesday. I think it expresses a sentiment about our experience here thus far – unbelievable. But, the pace has been hectic. I look at the Haitian doctors and nurses and OR staff and PIH volunteers who have been running at this pace since the Earthquake and I don’t know how they have been able to sustain it.
A Progression Toward More Discussion and Choice
Having said that, we have seen a progression in the types and kinds of medical and surgical issues we are seeing now compared to just ten days ago when we got here. The acuity of the problem is different. We are spending more time explaining to families what options they have with mangled limbs, open fractures, and chronic wounds. We have shifted from essentially “directing care” to increasing autonomy for the patient and their choices – of which they have many more now. When the limb is mangled and hanging by a few strands of tissue or overwhelmed with infection, the discussion is limited as are the options As we’ve moved from the acute presentation to the delayed, the need to “rush” these patients to the operating room is less and we are able to have more of a discussion with the patient and family.
Long-Term Response Needed
Yesterday, we did an above the knee amputation in a patient who was originally managed in PoP [Port-au-Prince] where he had a guillotine amputation. After his amputation, he realized he was simply in the queue in PoP, he managed to get himself to Cange for his definitive management, nearly 3 weeks later. You can imagine what the wound looked and smelled like. This is where we are headed in this country. The response needs to be sustained for some period of time or the system will break down.
But, how do you recover after an event like this that spans generations?
Captivating Church Music
Mike and I were able to witness a church group going through all the wards singing. They were accompanied by a priest who was also doing a prayer session. While I am not very religious per se, it was moving. We actually stopped what we were doing to listen – captivating.
Babak Sarani, MD, in his "Biopsy Bob" jersey. Photo by Samir Mehta.
I’ve decided to put names on the back of everyone’s scrubs (and numbers) – a la the former (and defunct) XFL. Derek is “77” and “The Big”; Mike is “33” and “It’s Okay”; Tom is “34” and “Life’s Good”; Babak is, shockingly, “1” and “Biopsy Bob”; Malcolm is “3” and “In the Middle”; Azura is “8” and “He Hate Me”; Amy is “13” and “He He He”; and Erica is “29” and “Stop It”.
A 3-Year-Old's Amputation
We have a three-year old patient who had a degloving injury of his right lower extremity. In addition, he had a previous amputation surgery but had missing skin over what was left of his right leg (which resembled a chicken bone). When we would round on him, he would always be with at least one parent. We would give the boy some pain medication / sedation for dressing changes so that he was comfortable as the dried gauze (after being wet) would débride his rather large soft tissue degloving over his residual limb. At least one parent was always present with the boy, but when you started to do a dressing change he would always ask for the other parent. In any case, we brought him to the Operating Room for a washout and skin grafting of his residual, degloved right tibia. There was bone exposed and the wound looked infected. We scrubbed the leg and performed a debridement. Consultation with some senior orthopaedic faculty back at Penn gave us reason to consider doing an below the knee amputation in this young boy. The family consented while the patient was still intubated with some assistance in Creole. I couldn’t believe that I was going to amputate a 3 year old’s leg. We did consult with both John Louie (our Haitian general surgeon working in Cange) as well as a senior general surgeon who arrived only the day before. They agreed as well that it was the right thing to do.
An Alleged "Fall"
I also say a boy today on rounds who had bilateral orbital trauma from a “fall”. Physical examination showed no signs of additional trauma. The boy had no additional face fractures, no other signs of trauma, and no obvious other injuries. The boy was likely a victim of child abuse. I couldn’t imagine the social system in place at a time like this to protect this child. The hospital might be the best place for him to be.
Making Some Headway
I am starting to feel like we are making some headway. We have 88 patients currently on the service, down from 118 previously. “Skin Graft Sarani”’s grafts appear to be taking quite nicely with little to no signs of sloughing. I am also content with the way that when someone looks at these radiographs they will understand why we did what we did based on the current situation.
Crazy and Hectic Code Response
One of our amputation patients was tachypneic this morning on rounds. Even she noted that she didn’t feel right. She was struggling to breathe. A Hgb came back at 3 (normal in the States is 12 to 15 or so). This was clearly not right, but with limited resources we began treatment for a PE and for blood loss. As the day wore on, it became harder for her to breathe and she was intubated for transport to PoP. Getting her (and the oxygen tank) out of the 2nd floor surgery ward and into the ambulance was a challenge – especially with four people riding in the back. As such, the spare tire was removed from the back and an attempt was made to try to fix it. The tire was left back. The entire code response was a bit crazy and hectic. I hope she does well.